After a financial health incentive program in Canada was scaled back following more than a year of full funding, improvements in physical activity dropped by about 200 steps per day, which was considered a statistically significant but not clinically meaningful decline, according to a new study.

For the most part, the authors concluded, physical activity can be maintained with less frequent and less costly financial incentive reinforcement, once it has been established.

“This study has real-world implications for government and corporate wellness programs that provide financial health incentives, like paying people to walk more,” lead author Sean Spilsbury, senior analyst at the Canadian Institute for Health Information in Toronto, told Medscape Medical News. Spilsbury conducted the research in his previous role as a kinesiology research assistant and graduate student at Western University in London, Ontario, Canada.

“These programs can be super expensive, especially when delivered on a population scale (whole cities or countries) and for longer periods (more than a year),” he said.

The study was published online November 8 in JAMA Network Open.

Boosting Physical Activity

From 2016 to 2019, three provincial governments in Canada — those of British Columbia, Ontario, and Newfoundland and Labrador — offered financial incentives for citizens to maintain physical activity goals through a mobile health app called Carrot. The app offered 4 cents CAD per day for completing personalized and adaptive daily step count goals, as well as team-based goals worth 40 cents CAD per week. Although the financial incentives were small, they were provided instantaneously as loyalty points and could be redeemed for items such as movie tickets or gas, the authors noted.

In December 2018, due to fiscal constraints, Ontario withdrew financial incentives for personalized daily physical activity goals, which represented a 90% reduction in incentives for physical activity earnings. The incentives remained in British Columbia and Newfoundland and Labrador, however.

To examine this change as a naturally occurring experiment, Spilsbury and colleagues designed a 25-week quasi-experimental case-control study, defining the intervention period as the 12 weeks before incomplete financial incentive withdrawal in Ontario, which spanned from early September to early December 2018. Since the Canadian winter holiday season could have influenced daily step counts, the weeks between early December through early January were treated as a pseudo-washout period to allow physical activity behaviors to stabilize. The research team examined the 8 weeks between early January and early March to understand the effects of financial incentive withdrawal on physical activity in Ontario.

Among 584,760 participants, all three provinces saw a downward trend from September to December, reflecting the seasonal declines expected during the colder winter season. Additional decreases occurred by March. The most pronounced decline was seen in Ontario: an average decrease of 367 steps per day, compared with a drop of 169 steps per day in British Columbia and an average drop of 93 steps per day in Newfoundland and Labrador.

The decline was most pronounced among highly engaged users in Ontario (328 steps per day), compared with low-engagement users (211 steps per day). In addition, physically active users in Ontario had a decline of 232 steps per day.

Physically inactive users were the only group in Ontario to show an increase, inching up 107 steps per day on average. Similarly, physically inactive users showed increases in British Columbia (234 steps per day) and Newfoundland and Labrador (187 steps per day).

Overall, incomplete financial incentive withdrawal led to modest physical activity declines of about 100 to 300 steps per day, depending on the analytical approach and the subgroup analyzed. However, the reductions are not clinically meaningful, the authors wrote, and represent a fraction of the initial increase after a year of exposure to the app — a jump of about 900 steps per day in general and 1800 steps per day among physically inactive users.

“Our study suggests incentives can be mostly scaled back without untoward effects on physical activity,” said Spilsburg. “This information may be relevant for government and corporate decision makers working within finite wellness program budgets.”

Sustainable financial incentive models are needed, Spilsbury and colleagues wrote. Without randomized clinical trials in this area, however, researchers must evaluate naturally occurring program changes to understand how financial reductions may affect interventions. In this case, for instance, modest declines may have occurred because the rewards for daily physical activity achievements were provided for more than a year before withdrawal began, which could be long enough for habit formation.

Long-Term Sustainability

Commenting on the findings for Medscape, Matthew Kwan, PhD, associate professor of child and youth studies at Brock University in St. Catharines, Ontario, Canada, and adjunct professor of family medicine and kinesiology at McMaster University in Hamilton, Ontario, Canada, said, “We know that when people initiate exercise, maintenance can be a big issue, with dropout rates of more than 50% in the first 6 months. It’s promising that this study showed initial increases in activity and a mitigation of the decreases that typically happen.”

Kwan, who wasn’t involved with this study, researches physical activity and behavioral changes throughout childhood and during the transition after high school. He and colleagues have created intervention programs through public-private partnerships to build physical literacy, motor competencies, and self-confidence in patients undergoing various life transitions.

“The question this raises is about the long-term sustainability of these models,” he said. “Although the financial incentives are promising, we need to figure out a more sustainable way this could work, where we’re not relying on government funding to get people to move,” such as insurance company incentives, corporate wellness programs, and public-private partnerships.

The study was funded by the government of Ontario through the Ontario Graduate Scholarship. Spilsbury and Kwan reported no relevant financial relationships.

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